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By Mark Hyman, MD
Table of Contents
Introduction: Why You Need This Guide Tests for Diabesity: Looking for Causes and Seeing the Effects Specialized Testing for the Underlying Causes of Diabesity: Identify Imbalances in the 7 Steps Medical Care for the 7 Steps Letter and Other Information for Your Doctor Diabesity Testing for Health Professionals: To Diagnose Presence of Diabesity Additional Tests for Diabesity: To Assess the Severity of Complications of Diabesity Diabetes: Asking the Right Questions Medical References
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Introduction:
Why You Need This Guide
Though there is much you can do to treat yourself for diabesity, working with a doctor experienced in a comprehensive approach to treating this problem is essential. Having a good relationship with a primary care physician and undergoing regular evaluations is critical in monitoring your treatment. However, there is one problem. The vast majority of physicians practicing today are not familiar with the methods I outlined in The Blood Sugar Solution. Some may not take a truly comprehensive approach to diagnosis and treatment of diabesity or be aware of or order the appropriate panel of tests. Others may not test you at all unless you have progressed down the path of disease. And most doctors interpret tests quite differently than I do, taking a wait and see approach, which can be dangerous.
In addition to having an annual physical examination and getting the right tests from your primary care physician, you should have an annual ophthalmologic (eye) exam to check for early signs of eye damage that can lead to blindness. Diabetic foot exams are also critical because the loss of sensation may lead to injury and ulcers, which can lead to amputations. These are not typically complications of insulin resistance, but must be monitored in diabetics.
As you now know, treating diabesity early and intensively is essential if you want to halt or reverse its progress. Getting your physician to assist you in this process by providing you with the correct tests and assessments is critical. That is why I have developed this guide. In it you will find: A complete list of tests I recommend for the assessment of diabesity and related conditions, including indications on how to properly read those tests Testing and additional medical treatments that are available for imbalances in the 7 steps A letter you can give your doctor that outlines the principles of Functional medicine and why this approach is essential in the treatment of diabesity
If you cannot get your primary care physician to cooperate in your treatment the way you want, you may need to consider looking for another doctor. However, it is my hope that with the tools in this guide you can work with your doctor to get the assistance you need. Good health care is a team effort between patient and doctor. I hope you can find someone you can work with to help you reverse your diabesity. (See the Resources section of The Blood Sugar Solution for information on how to find a practitioner of Functional or integrative medicine.)
While extensive testing isnt always necessary, basic testing can be very helpful in homing in on specific imbalances in your biochemistry that are creating problems for you. A number of laboratory tests may be useful in helping you identify your degree of insulin resistance, the severity of your diabesity, its complications, underlying causes, or contributing factors. I have divided these into two groups. The Basic Diabesity Tests help assesses the presence and severity of diabesity. The Additional Tests for Diabesity help determine the degree of dysfunction or problems that result from or contribute to diabesity, including inflammation, kidney and liver function, thyroid and sex hormone function, or nutritional deficiencies. In Chapter 17 on specialized testing for the underlying causes of diabesity, I will review the tests that help identify the underlying causes of diabesity, based on imbalances in the 7 key systems in the body. These tests help uncover specific nutrient deficiencies, food allergies, pesticide or heavy metal exposure, gut dysfunction, and more. These Basic and Advanced tests are ALL readily available from any doctor or laboratory, and they are important for screening for, evaluating, and monitoring diabesity. Most are available from Quest Diagnostics or LabCorp. If you have never had them done, do them all. If you have had recent tests, you can do these yearly or more often as recommended by your doctor to evaluate your progress. During the first year or two I recommend repeating these tests every four to six months. The specialty tests need to be selected based on consultation with a Functional or integrative physician, and need to be monitored and evaluated less frequently based on your individual needs and condition.
Testing Laboratories
Quest Diagnostics http://www.questdiagnostics.com/ A resource for most conventional laboratory testing needs. LabCorp https://www.labcorp.com/wps/portal/ A resource for most conventional laboratory testing needs. LipoScience http://www.liposcience.com/ Innovative nuclear medicine spectroscopy for the assessment of lipid particle size and improved accuracy in assessing cardiovascular risk factors. Doctors Data http://www.doctorsdata.com/home.asp Experts in testing for heavy metal toxicity and other nutritional and metabolic disorders. Metametrix http://www.metametrix.com Leaders in nutritional and metabolic testing. Genova Diagnostics http://www.gdx.net/ Leaders in nutritional and metabolic testing and genetic testing of SNPsinglenucleotide polymorphismsto help identify disease predispositions that can be modified with lifestyle interventions. Immunolabs http://www.immunolabs.com/patients/ IgG food sensitivity testing. Prometheus Labs http://www.prometheuslabs.com/ Leaders in testing for gluten-related disease. DiagnosTechs http://www.diagnostechs.com Testing for adrenal stress hormones. IGeneX http://igenex.com/Website/ Specialized testing for detecting chronic infections such as Lyme disease with PCR technology. Melisa http://www.melisa.org/laboratories.php Testing for the toxic immunological effects of mercury and other heavy metals.
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The insulin response test is probably the single most important test in all medicine to learn your risk of diabesity, heart disease, cancer, dementia, and premature death. It is cheap, easy, and any lab can do it, yet it is almost never done.
The test I recommend is a two-hour glucose tolerance test, with measurements of insulin and blood sugar checked after taking a 75-gm load of sugar (the equivalent of two sodas). You first measure fasting glucose and fasting insulin levels. Then you take the sugar drink and measure glucose AND insulin 30 minutes, one hour, and two hours later.
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Recent studies have identified fasting and the 30-minute insulin and glucose test as a sensitive alternative to the two-hour test to diagnose insulin resistance. Some people have a delayed insulin response, but the 30-minute test can be a quick way to do the test for most people. There are no agreed upon normals for these tests, but after doing more than 5,000 of them over 15 years, I can share with you what I think is optimal and ideal.
Fasting blood sugar should be less than 80 mg/dl. Thirty-minute, one-hour, and two-hour glucose should not rise above 110 mg/dl; some say 120 mg/dl.
Insulin Levels
Fasting insulin should be between 2 and 5 mIU/dl; anything greater than 10 mIU/dl is significantly elevated. Thirty-minute, one-hour and two-hour insulin levels should be less than 25 mIU/dl to 30 mIU/dl. Anything higher than 30 mIU/dl indicates some degree of insulin resistance.
The insulin response test is the most sensitive test available to identify insulin resistance and diabesity very early on and highlights the need for more aggressive approaches to treatment and care. It can also be useful in patients with diagnosed diabetes to see if they are still capable of producing insulin or if they have burnt out their pancreas. This can influence treatment recommendations. In some cases even a burnt-out pancreas can recover and diabetes can be reversed. For some, after decades of beating up their bodies with a toxic diet and lack of exercise, it may not be possible to reverse diabetes completely. But we can effectively treat everyone and prevent further complications with a comprehensive approach.
Hemoglobin A1c
Checking just one blood sugar reading doesnt tell you much about your overall blood sugar control. There is a test called hemoglobin A1c, or glycosylated hemoglobin, that can tell you if your overall blood sugar has been high over the previous six weeks. This test is used in monitoring diabetics but has now been proposed as a better way of diagnosing diabetes than just a random fasting blood sugar test. How To Work With Your Doctor 2012 Hyman Enterprises LLC
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Even in the face of normal fasting blood sugar your hemoglobin A1c can be high, because it measures your average sugar, including the effects of all the food you eat throughout the day. I use it to screen for overall blood sugar balance. Ideally it should be less than 5.5 percent of total hemoglobin. Anything higher than 6.0 is considered diabetes. Higher than 7.0 is considered poorly controlled diabetes.
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Unfortunately, the old way of testing cholesterol can lead to deceptive conclusions. You may have a totally normal total and LDL cholesterol but be at very high risk of a heart attack because it is the wrong type of cholesterol. In fact, more than 50 percent of people who show up in the emergency room with heart attacks have normal cholesterol. But they have small cholesterol particles, which are caused by insulin resistance. Lets look a little more deeply at the question of how to properly measure cholesterol.
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Optimal Levels
Microalbumin: <2 0 mg/dl BUN: < 20 mg/dl Creatinine: < 1.2 mg/dl
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range should be 100160 nmol/L or 4065 ng/ml. In the future, we may even raise this optimal level further. In fact, I like my patients to be between 6080 ng/ml. Monitor your vitamin D status until you are in the optimal range. If you are taking high doses (5,000 to 10,000 IU a day), your doctor must check your calcium, phosphorous, and parathyroid hormone levels every three months.
Sex Hormones
I recommend checking free and total testosterone in men, which is often low in insulin resistance and diabetes. This leads to muscle loss, fatigue, loss of motivation, low sex drive, and impotence.
I also recommend checking DHEA-S measurement of adrenal function as well as total and free testosterone and estrogen and progesterone, FSH (follicle stimulating hormone), and
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LH (luteinizing hormone) between days 18 and 23 of the menstrual cycle for premenopausal women and anytime for postmenopausal women. These are very helpful in identifying imbalances of hormones, which are common in diabesity. Women often have increased levels of testosterone and DHEA-S and a ratio of LH/FSH (luteinizing hormone to follicle stimulating hormone) of > 3:1.
Getting these tests will help you understand the nature and severity of your health risks associated with diabesity. Work with your doctor to get them all done so you both know what you are dealing with. It will inform your treatment, and they offer a good measure for how much you heal using The Blood Sugar Solution.
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Now lets look at all these tests in a little more detail. For each step I will outline the name of the tests I recommend and labs where they can be ordered. I will also provide details about what the test is and how it is useful in examining the optimal levels your doctor should be looking for with you.
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Essential fatty acids (omega-3 fats) are critical in normal blood sugar control and insulin function. And more than 90 percent of Americans are omega-3 fat deficient. Simply supplementing with omega-3 fats improves blood sugar control, reduces triglycerides and improves HDL, and lowers inflammation. However, there can be unusual fatty acid problems that specific tests may be helpful in uncovering. Here are the tests I recommend to assess problems with any of these nutrient levels:
OAT (Organic Acid Test): Urine Organic Acids Metametrix or Genova Diagnostics
Organic acids are byproducts of metabolism. They are helpful as a general nutritional and metabolic screening test. They help identify vitamin B deficiencies, including biotin, which is important in diabesity, as well as problems with fat, carbohydrate, and energy metabolism. They also help with oxidative stress, the gut, detoxification, and even
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neurotransmitter function. This is probably the single best-advanced test for evaluating diabesity because it covers so many problems with the 7 steps.
Testing for Thyroid Dysfunction (Part of Basic Testing for Diabesity) Quest Diagnostics, LabCorp, or Genova Diagnostics
There is no one perfect way, no one symptom or test result, that will properly diagnose low thyroid function or hypothyroidism. The key is to look at your symptoms and your blood tests, and then decide. Doctors typically diagnose thyroid problems by testing your TSH levels and sometimes your free T4 level. But some doctors and researchers have brought the normal levels of those tests into question. The diagnosis of subclinical hypothyroidism depends on having a thyroid-stimulating hormone (TSH) level higher than 5 mIU/L and lower than 10 mIU/L. But new guidelines from the American College of Endocrinologists suggest that anything higher than 3 mIU/L is abnormal. This number is an improvement but still may miss many people who have normal tests and a malfunctioning thyroid system. To get a complete picture, I recommend looking at a wider range of function: TSH (ideal is between 1 and 2 mIU/L). Testing for free T4 (ideal level is 11.4 ng/dl) AND free T3 (ideal level is 300400 pg/dl), which are the inactive and the active hormones. Thyroid antibodies (TPO) or autoimmune thyroid antibodies. Most doctors dont check this UNLESS the TSH is high. This is a big mistake. Many people have autoimmunity against their thyroids, which makes it function poorly, but still have normal TSH. Thats why I think this should be part of routine screening. Basal normal body temperature is 98.6 degrees F. This is measured with a special basal body thermometer you can obtain at a pharmacy. Check your temperature before getting out of bed in the morning. If you are a menstruating woman, check it
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only between the first and third days of your menstrual cycle (the first day is the first day of bleeding).
Testing for Sex Hormone Imbalances (Part of the Basic Tests for Diabesity)
Testing for sex hormone imbalances in women is tricky because levels change throughout the menstrual cycle. Postmenopausal testing is easier. The best time to test for hormones in premenopausal women is anywhere between days 18 and 23 of the menstrual cycle. For postmenopausal women, anytime is fine. Hormone testing is essential to monitor the effects of bio-identical hormone replacement.
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IgG Food Sensitivity (Special Antibodies Tests against Food) Immuno Laboratories or Genova Diagnostics
While still controversial, well-controlled studies have shown that these tests are helpful in identifying problem foods. Removing these foods helps inflammatory problems. I have found these tests to be imperfect though helpful guides in locating trouble foods.
Elimination/Provocation
This is simply the process of removing potentially allergic foods like gluten and dairy from your diet for two weeks, then reintroducing them and monitoring how you feel. The Blood Sugar Solution has a six-week gluten and dairy elimination and provocation test built into it. My book and home study course, The UltraSimple Diet, describes a more comprehensive elimination diet if you need it.
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Hidden Infections Quest Diagnostics, LabCorp, Medical Diagnostic Laboratories, or IGeneX Labs
You can have a chronic, smoldering infection that leads to an activation of your immune system and promotes system-wide inflammation. If inflammation persists despite changing your diet and lifestyle, taking supplements, and addressing food allergies and insulin resistance, then you may have a hidden infection. There are many tests that identify hidden infections.
General Gut Health, Bacterial Balance, and Parasite Testing: Stool Analysis for Dysbiosis Metametrix, Genova Diagnostics, or Doctors Data
Many chemical markers in the stool can be analyzed to give a picture of the ecosystem. Markers for digestion, absorption, acid-alkaline balance, as well as cultures of various bacteria, yeasts, or parasites can often pinpoint the sources of inflammation and be linked to many diseases. Some conventional labs do test for parasites but are often not experienced and miss many infections. Newer tests even assess the DNA of microbes in the gut through PCR testing of the entire gut ecosystem and can identify the balance of good and bad bugs in the gut.
Urine Organic Acid Test (OAT) for Bacterial and Yeast Metabolites Metametrix or Genova Diagnostics
Organic acids are metabolites in the urine that can give clues to nutritional status, but the organic acid test is often used to look at unusual chemicals that come from the gut, such as
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bacteria, yeasts, or parasites. The test can be helpful in identifying problems and tracking treatment, but even a negative test doesnt rule out significant imbalances in the gut. Currently we can measure only some of the activity, not all of it.
Chelation Challenge
Doctors Data or Genova Diagnostics
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The chelation challenge test is often better than any other test at identifying the levels of heavy metals. An FDA-approved chemical chelation agent called DMSA (challenge dose is 30 mg/kg) can be used to mobilize the metals that are found in a 24-hour urine sample that is collected and sent to the lab. DMPS, sold over the counter in Germany and used widely in Europe and Russia, is another well-used chelating agent that can be used for testing or treatment. The challenge dose is 250 mg for children and 500 mg for adults. It is not FDA approved but is legally available from compounding pharmacies in the United States.
Whole Blood or Red Blood Cell Heavy-Metal Levels: Lead, Mercury, Arsenic, Etc.
Quest Diagnostics, LabCorp, Doctors Data, Metametrix, or Genova Diagnostics
Even though this is the test used by conventional doctors to screen for metals, it is ONLY accurate in picking up very recent exposure (the last 120 days) because most of the toxic metals are cleared quickly from your bloodstream and are stored in your tissues and bones for decades.
Chemical Testing
I rarely perform chemical tests because I assume nearly everyone has some degree of chemical toxicity. Body burden studies have been done through the Environmental Working Group (www.ewg.org) and the Centers for Disease Control and Prevention (www.cdc.gov/exposurereport) and have found hundreds of chemicals in everyone. For more serious or acute exposures, certain tests that identify chemicals can be helpful. For example, blood levels of PCBs, solvents, and pesticides can be tested. You can order these tests through Metametrix.
Step #6: Enhance Energy Metabolism: Identifying Loss of Energy and Oxidative Stress
We can test for mitochondrial function and oxidative stress, which is very important in diabesity. We can identify the effectiveness of fat and carbohydrate metabolism and
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cellular energy production as well as important markers of free radical or oxidative stress damage. Here is what I recommend.
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Oxidative Stress Testing: Lipid Peroxide Assays in Urine or Serum or TBARS Metametrix or Genova Diagnostics
This provides indicators of rancid or oxidized fat in the body, especially the fats from our cell membranes. It is an excellent indicator of oxidative stress.
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There are two products I recommend that are wonderfully effective: Healing Rhythms by Wild Divine emWave by HeartMath Now that we have covered the tests you need, in the next chapter we will review some of the medical treatments available to help you rebalance these key systems in your body.
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whats available and what to ask about can empower you to make better decisions about your health. A combination of experience, testing, and trial and error is necessary to get it just right. However, I have found that the majority of my patients benefit from a combination hormone treatment including T4 and T3. Synthroid, the most commonly prescribed thyroid hormone, is just T4, the inactive hormone. Most doctors assume that the body will convert it to T3 and all will be well. Unfortunately, pesticides, stress, mercury, infections, allergies, and selenium deficiencies can block that process. Since 100 percent of us have stored pesticides in our bodies, we will all likely have some problem with Synthroid.
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deficiency), its the right choice. Occasionally, further customization of thyroid hormones is necessary using various combinations of T4 and T3 in prescription or compounded forms. Once started it doesnt have to be taken for life (a common misperception). Sometimes, once all the factors that disturb your thyroid have been corrected, you may be able to reduce or discontinue the dose. As with any treatment, always work with an experienced physician in using medications for your thyroid. Careful monitoring is essential. Taking too much thyroid hormone, or taking it if you dont need it, can lead to undesirable side effects including anxiety, insomnia, palpitations, and, over the long term, bone loss. WARNING If your adrenal glands are burned out from long-term stress, treating the thyroid without supporting the adrenal glands through relaxation and adaptogenic herbs (such as ginseng, rhodiola, or Siberian ginseng) can actually make people feel worse. Your Functional or integrative medicine practitioner will know how to balance your adrenal glands before treating your thyroid with medication.
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For severe cases of PMS not improved by diet, lifestyle, or supplements, your doctor may try: Topical, natural, bio-identical progesterone in the last two weeks of the menstrual cycle; the usual dose is tsp (2040 mg) applied at night to thin skin areas of your body during the last two weeks of the menstrual cycle
For mens hormone balance your doctor may use: Testosteronetopical is ideal after measurement of your hormone levels and with ongoing monitoring of testosterone and PSA levels DHEA supplementation
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Occasionally, odd hidden infections, including hidden dental infections in old root canals or hidden viral or bacterial or tick-borne infections, can be a source of chronic inflammation. These need to be hunted down and treated on an individual basis. Finally, learning to find the pause button and reduce the effects of chronic stress can cool the fires of inflammation for many. Each person is unique, and many need specific treatments for the cause of inflammation that include the use of antimicrobials like antibiotics or antifungals and chelating agents. An experienced practitioner of Functional or integrative medicine will recommend these treatments as needed. The key thing to remember is that it often takes persistence and diligence to find the source of the inflammation and treat it directly. But with time this can be done and is remarkably more effective than anti-inflammatory medications such as steroids, Advil-like medications, or immunosuppressive or immune-blocking medications. And with much fewer side effects.
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So you can try working to fix your gut on your own, but if things dont improve, it may be time for testing and medication with your doctors help. Remember, if you are standing on a tack, it takes a lot of aspirin to feel better. If you have too much bacteria, yeast, or a parasite, you can eliminate all the foods you like or add all the healthy bacteria, but it may be an uphill battle unless you fully address any imbalances or infections with bugs in the gut.
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Aside from addressing hidden food allergens and helping people balance their blood sugar and consume a whole-foods diet, one of the most powerful ways to correct many chronic health problems is a medically supervised heavy-metal detoxification program. Proper testing, preparation, and care are needed in order to achieve safe and effective heavy-metal detoxification. Below you will find the steps I often recommend to prepare my patients for heavy-metal detoxification. I will also outline the options available for treatment. I want to reinforce that this must be done with a qualified health care practitioner. Below I describe the most important steps to help prepare you for safe metal removal. Once you have improved your health and optimized your detoxification system, you can begin working to remove metals from your body through various approaches including safe amalgam or silver-filling removal (see www.iaomt.org) and the use of chelating agents such as DMSA, which is a prescription medication designed and approved for lead removal in children, but also effective against mercury and many other toxic metals. While there needs to be more research done in this area, the current body of evidence, my experience, and the experience of thousands of other doctors and patients make it clear to me that this can be a critical part of the process of healing for chronic illnesses, including diabesity. To read an excellent consensus position paper on heavy-metal detoxification called Defeat Autism Now! that was developed by a group involved with autism treatment, go to www.autism.com/triggers/vaccine/heavymetals.pdf. Recognize that there is much controversy in this area as well as many opinions on the best way to detoxify from heavy metals. I humbly offer my hard-won and personal observations and knowledge on how to do this safely and effectively. Getting Ready for Detoxification These are the general guidelines I use with my patients that I recommend you follow with your doctor. They should generally be done in collaboration with your health care provider and may take a few months. First, optimize your gut function by eliminating common food allergens and taking probiotics and enzymes for one to two months before detoxifying.
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Optimize your nutritional status for detoxification using healthy fats (omega-3 fats, olive oil, and flax oil); the amino acids noted above (which boost your livers detoxification capacity); and minerals, particularly zinc and selenium (which help your body detoxify metals). Enhance your livers detoxification pathwaysespecially the sulfation and methylation pathwaysby taking folate, B12, and B6; eating foods that contain sulfur, such as broccoli, collards, kale, daikon radish, garlic, onions, and omega-3 eggs; and supplements such as alpha lipoic acid and N-acetylcysteine. Use herbal support for heavy-metal detoxification, including alginate, cilantro, garlic, and milk thistle. Start sauna therapy and make sure that you take adequate electrolyte and mineral replacements to prevent dehydration and mineral loss from the perspiration. Optimize elimination routes for metals through your urine, stool, and perspiration by drinking plenty of clean pure water, eating a diet high in plant fibers, and taking daily saunas for 30 minutes.
Once you have prepared for the process of detoxification using the steps above, you can then begin detoxifying from heavy metals by using chelating agents. However, you must work with an experienced physician to do this.
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In order to best partner with your doctor to get the tests and treatments outlined in The Blood Sugar Solution and in this guide, try photocopying these materials and giving them to your physician. I hope it helps convince your medical practitioner to join in the revolution that is happening in medicine today.
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Dear Doctor: In my practice, I have found the diagnosis and treatment of diabesity (the continuum of insulin resistance from metabolic syndrome to diabetes) to be one of the more rewarding aspects of patient care. Diabetes and metabolic syndrome combined affected well over 100 million Americans and close to 1 billion people worldwide. According to research published in Diabetes Care in December 2009, the diabetic population will rise to 44.1 million in 2034, from 23.7 million now, with medical spending increasing to $336 billion from $113 billion. Double the patients, triple the cost. Clearly what we are doing to treat this pandemic is not adequate. Early diagnosis and comprehensive treatment is necessary to stem this tsunami of disease and its social and economic burden. Insulin resistance is also a major underlying process that contributes not only to diabetes, but also to most cardiovascular disease, dementia and most common cancers. The phenomena of insulin resistance and diabetes emerges from the interaction of genetic predispositions and environmental insultsour highly-refined, processed, high-sugar, lowfiber, high-fat diet; our sedentary lifestyle; chronic stress; and, increasingly, environmental toxins. Over the last few decades the mechanisms of explaining how these gene-environment interactions lead to disease have become clear. Our toxic diet, lifestyle, and environment trigger secondary phenomenon of nutritional deficiencies, inflammation, oxidative stress, mitochondrial dysfunction, digestive imbalances, hormonal dysfunction (thyroid and sex hormone) and effects of environmental toxins such as persistent organic pollutants and heavy metals on metabolism. These underlying mechanisms lead to the clinical phenomena we treat: hyperglycemia, hypertension, hyperlipidemia, and coagulopathy. However, these numbers are simply risk factors, clinical indicators that are downstream from the real causes. And treating risk factors alone will not address the underlying systemic causes that drive insulin resistance. We need to move beyond risk factor management to treatment of the causes of the disease. The real causes are our 21st century diet, sedentary lifestyle, chronic stress, and environmental toxins. Addressing these upstream causes in a comprehensive and systematic program will correct the mechanisms (inflammation, oxidative stress, mitochondrial dysfunction, etc.), which in turn will resolve the risk factors that we treat hyperglycemic, hypertension, and hyperlipidemia. What we do now is often more akin to How To Work With Your Doctor 2012 Hyman Enterprises LLC
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mopping up the floor while the faucet runs and the sink continues to overflow. We need to turn off the faucet. That is why I prepared a home study course on diabesity for my patients and consumers based on 20 years of practice treating thousands of patients with diabesity. I hope you receive this letter in the spirit of inquiry and cooperation that I believe is needed for patients and physicians to find the best possible treatment for each person. Your patient has read my report and home study course on diabesitythe continuum of metabolic syndrome and diabetes. My approach is based on the science of functional medicine, a systems biology approach to dealing with chronic illness that attempts to assess the underlying network of causes and factors that promote disease as well as incorporating strategies to optimize and enhance normal gene expression, biochemistry, and physiology. The key things that I have identified from my practice and research include the following: 1. Metabolic syndrome and diabetes are best approached through comprehensive lifestyle and environmental change. The data supports this approach as more effective than medication or surgery. 2. Specific tests can help in the early assessment and diagnosis of metabolic syndrome, as well as assess the severity of metabolic syndrome and diabetes. Some of these tests may be familiar, while others are not. Lipid particle size, for example, is a critical part of assessment of the dyslipidemia associated with metabolic syndrome. 3. Monitoring a basic panel of tests is necessary, as well as some additional tests that assess the secondary phenomena associated with insulin resistance such as fatty liver, inflammation, thyroid dysfunction, androgen deficiency in men, and androgen excess and PCOS in women. 4. Treatment of metabolic syndrome and diabetes with a low glycemic load, high-fiber, nutrient-dense, plant-based diet; regular exercise; stress management tools; reduction of exposure to environmental toxins; and selective research-based nutritional supplementation such as omega-3 fatty acids can more effectively treat the disease than medication and often even reverse the pathology. This can reduce overall medical expenses, care, and morbidity and mortality. My home study course entitled The Blood Sugar Solution provides patients with all the tools they need for self-care to implement the lifestyle changes needed to address this epidemic. However, I have encouraged them to partner with their physician for testing, monitoring of How To Work With Your Doctor 2012 Hyman Enterprises LLC
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their care, and adjustment of medications as needed as they become healthier. As a practicing physician, I know that most of us neither have the time, nor often the training to teach our patients about sustainable behavioral and lifestyle change. I work closely with a nutritionist, but most do not have that luxury. This home study course, I hope, can be an adjunct to your practice and allow you to provide your patients a comprehensive approach to change that addresses the causes of their metabolic syndrome and diabetes. With that in mind I have provided here what I hope are some useful tools, references and resources: 1. A list of the basic tests and interpretation that I use in my practice to monitor patients with metabolic syndrome and diabetes. I hope you will find them helpful and useful in monitoring your patients. 2. An editorial I published in 2006 entitled Diabetes: Asking the Right Questions explaining some of the science behind this approach. 3. An extensive list of references documenting everything I have said or recommended in this letter and the home study course. Thank you for taking the time to review this letter. I encourage you to consider this perspective in your practice. I would like to offer this home study course as a support for your patient care. If you would like further information on the field of Functional medicine and more detail about how to address our burden of chronic disease using a systems approach, I encourage you to read the Textbook of Functional Medicine. For further resources and training including the Certification Program in Functional Medicine, please visit www.functionalmedicine.org.
Sincerely,
Mark Hyman, MD
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Thirty-minute and one-hour and two-hour should be less than 25 IU/dL to 30 IU/dL. Anything higher than 30 IU/dL indicates some degree of insulin resistance.
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o The level of free T3 that is normal is considered to be between 240 and 450 pg/ml, depending on the laboratory measurements. However, the reference ranges for laboratory tests are often based on normal populations. (Remember normal means the average of population, not necessarily the ideal.) TPO (thyroid peroxidase) and antithyroglobulin antibodies: Autoimmune antibodies in the thyroid gland that interfere with its function. These should both be less than 20 IU/mL.
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Ed i t o r i a l
Mark Twain
n science, as in life, we receive answers to only the questions we ask. How is this true in the explosive increase in diabetes worldwide? How might diabetes be a model for a new way to diagnosis and treat chronic complex illnesses? Unfortunately, we are married to definitions and risk factors and not exploring more fruitful lines of inquiry. We are mired in asking the wrong questions, much like the religious sages of the middle ages who wondered how many angels could dance on the head of a pin. What is the correct definition of diabetes or insulin resistance or metabolic syndrome or pre-diabetes? Should we be excited by the latest drug therapy or gene discovery in diabetes? What about CAM therapies? Should we be assessing old or new therapies as green drugs to control blood sugar or lipids? Are these useful questions or simply distractions from the more important question of how to deal with diabetes from a cultural, social, political, etiologic, and comprehensive systemic, biological perspective? Does asking the wrong questions distract from the larger notion of discovering the causes of disturbances in the dynamic continuum of our metabolic equilibrium and their remediation? Does asking the wrong questions deflect from inquiry into the critical processes of restoring self-regulation to our complex biology? I would argue that the answer to these questions is yes. Understanding that illness has purpose and that disease is generally rooted in the bodys attempt to correct underlying imbalances or dysfunction, we can seek to not alter, block, or interfere with normal metabolic processes, but to learn how to enhance, facilitate, and promote normal function. Symptoms are clues to deeper molecular, metabolic, and psycho-spiritual problems. They are welcome signposts guiding us to the imbalances, dysfunction and causes of illness. Symptoms are not enemies to be silenced, but friends that can orient us in the maze of metabolic accommodations resulting from the collision of genes, environment, and lifestyle we call disease. So how do we reorient ourselves to more effectively address
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DiabetesAsking the Right Questions
meal (wild salmon, wine, dark chocolate, almonds, fruits, vegetables, and garlic) might be a more effective and sensible solution with greater benefit.6 The simplicity of this perspective is founded in 2 guiding clinical notions. First, find and remove or correct the obstructions to normal biological function (and they are fewgenes, dietary inputs, toxins, infections, allergens, and stress). Second, provide the more natural conditions (necessarily unique to each individual) for proper biologic and psycho-spiritual functioning (they are also fewquality protein, fat, carbohydrates, vitamins, minerals, phytonutrients, conditionally essential nutrients, water, air, sleep, rhythm, love, community).7 The name or definition of disease and the treatment of disease become less important than correcting the internal milieu that gave rise to symptoms. We cannot escape the exigencies of being born into the animal world, dependent on nature and each other in order to thrive. SIDETRACKED BY THE NAME A recent pair of editorials in the American Journal of Clinical Nutrition argued the merits and limitations of the various definitions of metabolic syndrome, a precursor to diabetes, and a significant disease risk factor unto itself. Gerald Reaven, the physician who first coined the term Syndrome X, later called metabolic syndrome, believes that while this appellation is useful in research, the concept has no clinical utility.8 It distracts, he says, from the more important task of identifying and treating each risk factor separately and aggressivelycontrol the blood pressure, the lipid profile, the inflammation, the coagulopathy, and the glucose metabolismand applies equally to metabolic syndrome or diabetes. The World Health Organization, the Adult Treatment Plan III (ATP III), and the International Diabetes Federation all have different definitions of metabolic syndrome, including with varying importance abnormal fasting or post glucose load glucose, highdensity lipoprotein (HDL) and triglyceride levels, blood pressure, and obesity or waist circumference. While this homogenization of definitions may have academic utility, it is not particularly helpful in working with the single patient in a clinical setting. The problem with names and labels is that they abort the thinking process. They abort thinking about the state of a persons individual constitutiontheir unique genetic constellation interacting with their nutritional, immune, endocrine, or overall metabolic statewhat has been referred to as the biological terrain or internal milieu. That terrain might be a better starting part for clinical disease management than attempting to match a patient to an existing or new International Classification of Diseases (ICD-10) definition. Many patients will not fit into the box of diagnosis. Some may have normal lipids or glucose but severe hyperinsulinemia, or central obesity, but normal glucose metabolism. They also may have different precipitating causes from dietary indiscretions to inflammatory or toxic etiologies layered upon a sea of genetic variation. Grundy, in an accompanying editorial, makes the argument for an understanding that recognizes the interaction of all aspects of the syndrome dyslipidemia, dysglycemia, hypertension, vis-
ceral obesity, inflammation, and coagulopathyas a unifying principle that can help in early pattern recognition of metabolic derangement. Grundy reminds us that, Whereas single-disorder organizations and sub-specialties may find it difficult to embrace risk-factor clustering as a new prevention paradigm, its reality makes a move in this direction virtually inevitable.9 Perhaps treating the risk factors is less important than treating the patterns they form at their root. Taken in isolation, any studywhether basic science or translational clinical researchprovides a limited guide for clinical care. Yet when considered together, patterns, themes, principles, and guiding concepts emerge. The National Institutes of Health (NIH) New Roadmap initiative recognizes the importance of systems thinking, patterns, and networks of function in disease and health. And the NIH is supporting basic research in this area. Yet the gap between basic sciences, epidemiology, and clinical care is vast because our approach to chronic conditions like diabetes is focused on treating downstream effects, and not a comprehensive view of the causes and their remediation. If the disease is primarily a lifestyle, nutritional, and metabolic disorder, why do we seek new drugs or employ outdated dietary recommendations from organizations such as the American Diabetes Association, which ignores the reality that the content of food is equally important as the calories? BEYOND THE NAME: SEARCHING FOR MEANING AND ORDER IN CHAOS So what do we know about the causes of diabetes or metabolic syndrome? What do we know about the various factors that influence its expression? And what do we know about the ways to influence genes and metabolism that reorganizes the abnormal patterns of function that appear clinicallythe hyperinsulinemia, dyslipidemia, inflammation, oxidative stress, mitochondrial dysfunction, coagulopathy, hypertension, and central obesity? Is there a way of thinking and treating the patient in the clinic that addresses all of these problems simultaneously without addressing any one of them individually or directly? The answer, I believe, is yes. I propose that diabetes is a clinical model for a problem that is endemic to clinical medicinetreating the symptoms, not the causeand that understanding how to improve the biological terrain; optimize nutrient status; improve gene expression through specific nutrients and phytonutrients; and regulate immunity and metabolism via lifestyle interventions such as diet, exercise, stress management, and adequate sleep collectively can have a much greater impact than any pharmacologic treatment. What does the evidence indicate might play a role in the development of insulin resistance, metabolic syndrome, and type 2 diabetes? A key epidemiological study by Willett et al assessed the collective effects of an improved dietary pattern (low glycemic load, high cereal fiber,10 high polyunsaturated and monounsaturated11 fatty acids, low trans fats); moderate to vigorous exercise 30 minutes per day; no current smoking; and the consumption of half an alcoholic beverage per day. It was esti-
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11
mated that in the 84,941 women followed in the study, 91% of all diabetes could be prevented.12 There are hundreds more genes that help us adapt to starvation than to excess calories. Learning to influence gene regulation and expression through dietary, lifestyle, and environmental influences on PPAR and nuclear factor kappa binding (NFkB) and other key receptors and transcription factors is critical. Over 35% of our calories come from 2 engineered foods foreign to human genes and biologythe genetically novel epic monocultures of corn and soybeans that infuse nearly all industrial foods produced through commercial agriculture or food processing.13 These industrial foods have untoward effects on human physiology and metabolism. They alter and become our cellular structure. Eating whole foods, native in design and beneficial to gene expression and cellular functioning is more sensible (and scientifically sound), than forming our cells and tissues of recently developed material that is biologically questionable. The information in food and the science of nutrigenomics14 is a more useful guiding paradigm in the treatment of disease than understanding food as simply a source of energy, with all calories being equal in their metabolic effects. The research points in quite a different direction. The quality and source of fat, carbohydrate, and protein qualitatively and quantitatively influences all the biological systems involved in insulin resistance and type 2 diabetes. Plantbased whole-food dietary patterns can prevent or even reverse underlying pathologies and metabolic dysfunction.15 Dietary fatty acid composition also plays a critical roleeliminating trans and saturated fats and increasing omega 3 and monounsaturated fats improves all parameters of diabetes and metabolic syndromethe hyperinsulinemia, dyslipidemia, inflammation, oxidative stress, mitochondrial dysfunction, coagulopathy, hypertension, and central obesity. 16 Carbohydrate quality is equally importantlow-glycemic-load and -index carbohydrates with a high fiber content have similar benefit.17 Adequate protein nutrition also plays a role in glucose metabolism and can improve skeletal muscle function and reduce post-prandial lipids, insulin, and glucose and grehlin secretions.18 Elimination of red meat from the diet improves microalbuminuria and fatty acid profiles in people with diabetes.19 Dietary fiber has salutary effects on weight, lipids, and glucose metabolism and is equivalent to sulfonylureas in lowering glycated hemoglobin.20 Micronutrients such as chromium, zinc, magnesium, biotin, vitamin D, the B vitamins, and antioxidants also might play a key role in modulating the various components of metabolic syndrome.21 Conditionally essential nutrients such as lipoic acid, coenzyme Q10, and carnitine also play a physiologic role in metabolic syndrome. 2 2 Phytonutrients such as the carotenoids,23 almonds,24 soy, and phytoestrogens25 influence gene expression, favoring insulin sensitivity, and reduction in lipids, oxidative stress, inflammation and coagulopathy. Other key lifestyle factors affect our metabolic equilibrium as well. Exercise alters skeletal muscle metabolism and improves glucose uptake, reduces low-density lipoprotein, raises HDL,
lowers blood pressure, and reduces inflammation and oxidative stress.26 Autonomic dysfunction with sympathetic over-activity exacerbates insulin resistance and lipid and glucose metabolism and promotes central obesity.27 Therefore, techniques to enhance parasympathetic and reduce sympathetic activity, such as yoga or meditation, can have protective or even therapeutic benefit in metabolic syndrome and diabetes. While these therapies may have a small or limited benefit when studied in isolation, when taken together to approximate the more natural conditions, foods, and activities with which we evolved, they can dramatically help prevent and treat the sentinel disease that is a central cause of the accelerating epidemic of degenerative diseases including cardiovascular, neurodegenerative, and neoplastic conditions that afflict our aging population and our children. Disease is not a natural consequence of life to be accepted, but a reflection of the loss of the natural and evolutionary conditions necessary for self-regulation and healing. It is the bodys best attempt to restore balance given a difficult set of circumstances. Learning to restore our capacity for self-regulation and metabolic equilibrium is the hope of the next generation of medical scientists and practitioners.
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